A study to assess the effect of maternal hemoglobin level on foetal outcome among antenatal mothers in selected maternity hospitals at Mangalore

In developing countries maternal anemia during pregnancy has been reported to increase the risk of unfavorable foetal outcome. According to the standard laid down by WHO, anemia in pregnancy is present when the hemoglobin concentration in the peripheral blood is 11gm\100ml or less. In India its prevalence has been found to be in the range of 50-90% in 3 rd trimester of pregnancy according to different studies conducted in rural areas. Maternal anemia in pregnancy is commonly considered as risk factor for poor pregnancy outcome and can threaten the life of mother and foetus. However, the extent to which the maternal hemoglobin concentration affects the foetal weight and foetal outcome is still uncertain. In the present study the researcher will investigate the possible effects of abnormal maternal hemoglobin level on foetal outcome. Interpretation and Conclusion: The findings of the present study revealed that there is a relationship between maternal hemoglobin level and fetal outcome such as birth weight, color of the new born, muscle tone, pre term birth and gestational age of the new born. A review of previous studies done showed that the risks of preterm delivery and LBW increased in proportion to the severity of maternal anemia. A comprehensive community based intervention with iron supplementation, helminthes treatment and increase in knowledge regarding information, education and communication through effective strategies, to improve the hematological status of pregnant women in each trimester, is needed and there by reduces maternal and fetal mortality and


Introduction
In developing countries, maternal anemia during pregnancy has been reported to increase the risk of unfavorable foetal outcome 1 .According to the standard laid down by WHO anemia in pregnancy is present when the hemoglobin concentration in the peripheral blood is 11gm\100ml or less 3 .Hemoglobin concentration less than 50gm\L significantly increase the risk of maternal and foetal mortality because of the effect of hypoxia and anemia on the cardio vascular system, which is known as high-output heart failure.Medical evidence shows that very severe anemia is a direct cause of maternal and child mortality 2 .Once hemoglobin concentration reaches greater than 180gm\L, the blood viscosity reaches a level that impairs micro circulation so that an inadequate amount of oxygen is transported to tissues, similar to the situation with severe anemia 1 .Several epidemiologic studies showed that both low and high hemoglobin concentration are associated with increased adverse birth outcomes including foetal death, IUGR, pre term delivery and low birth weight. 4the relationship between maternal hematological parameters and pregnancy outcome has been a source of continuing controversy.In developed countries, not only maternal anemia but also high hemoglobin concentration during pregnancy has been reported to increase the risk of unfavorable foetal outcome. 5In India its prevalence has been found to be in the range of 50-90% in 3 rd trimester of pregnancy according to different studies conducted in rural areas.It has got a severe impact on maternal and perinatal outcome, contributing directly and indirectly to maternal and perinatal mortality and morbidity 6 .
It is regrettable because most of the cases of severe anemia in our country are preventable as they are due to deficiency of iron, folic acid, essential amino acids etc. caused by inadequate intake of these essential ingredients in food.It is further aggravated by factors like repeated pregnancy at too short intervals, worm infestation, recurrent hemorrhage etc.Most of which are associated with illiteracy and poor hygiene. 7In the developing world, current strategies, to prevent and correct anemia and iron, deficiency in pregnant women has met with little success.Two large studies in the industrial world, involving over one million pregnancies clearly indicated that favorable pregnancy outcomes are less frequent among anemic mothers. 8Maternal anemia in pregnancy is commonly considered as high risk factor for poor pregnancy outcome and can threaten the life of mother and foetus. 9Amount of iron transferred to the foetus is unaffected even if the mothers suffer from iron deficiency anemia but the incidence of low birth weight babies and pre mature births are common.Regular antenatal care from first trimester has a vital role in assessing and managing maternal anemia timely and it directly affects the perinatal outcome. 10

Research approach
The research approach adopted for this study was descriptive research approach as the researcher aimed at determining the effect of maternal hemoglobin level on foetal outcome.

Research design
The research design selected for the present study was non experimental descriptive design.The study was planned to find out the effect of maternal haemoglobin level on foetal outcome

Setting of the study
The study was conducted in the antenatal and labour ward of Govt.Lady Goschen hospital, Mangalore.

Sample and sample size
The sample for the present study consisted of 50 antenatal mothers who are in 1 st stage of labour in the month of September 2009

Sampling technique
The antenatal mothers were selected using non probability purposive sampling technique.Non probability purposive sampling technique is selected based on the judgment of the researcher to achieve particular objective of the research.

Development of the tool
In this study the investigator has used, demographic proforma for mother and baby and Dubowitz maturity assessment scale which was prepared based on the review of literature and in consultation with experts in the field of pediatric nursing and obstetrics and gynecological nursing.

Data collection procedure
Data was collected from 1-9-2019 to 30-9-2019(30 days).The articles required to carry out the procedure were collected.The steps of haemoglobin level assessment by sahli's method were strictly followed and foetal outcome was assessed by attending the labour and maturity of the new born was assessed by Dubowitz maturity assessment scale.The study population consisted of 50 antenatal mothers who are in 1st stage of labour.The data was collected and recorded systematically on each subject and was organized in a way that facilitates computer entry.

Plan for analysis of data
Descriptive statistics are useful for summarizing empirical information.Inferential statistics, which are based on laws of probability, provide a means for drawing conclusions about the population from which the data is obtained for sample.44Data would be analyzed by following steps:  Organizing the data in master sheet  Frequency & % of data will be calculated for describing demographic variables. Mean, and standard deviation will be used to present hemoglobin level. Chi square test will be used to find the association between maternal hemoglobin level with selected demographic variables  Chi square test will be used to find the relationship between maternal hemoglobin level with foetal outcome.

Organization of the findings
The results have been organized and presented in four parts.

 PART 1 -description about demographic characteristics
o PART I -A -demographic proforma for mother o PART I-B-demographic proforma for baby  PART II -hemoglobin level among antenatal mothers  PART III -relationship between maternal hemoglobin level and foetal outcome  PART IV -association between maternal hemoglobin level and selected demographic variables   Third and above 6 12

PART I: Description about demographic characteristics PART I -A -Demographic proforma of mother
Data presented in table no.6 shows that highest percentages (54%) of the samples were male and only 46% were female.This table also reveals that majorities (70%) of the new born were first babies, 18% were second babies and only12% were third babies.This part deals with the demographic characteristics of babies in terms of birthweight as shown in table 7.This depicts that highest percentage (58%) of the samples were between 2.5-3.5kgand42% were <2.5 kg.No one is included in the group ofgreaterthan3.5 kg.The demographic characteristics of the babies in terms of pre term birth areshown in table number 9. It reveals that 36% of the samples were pre term babies and64%weretermbabies.The demographic characteristic of the babies in terms of intra uterine growth restriction is shown in table number 10.
It reveals that 96% of the samples had no history of intra uterine growth retardation and only 4% had intra uterine growth retardation.

PART II -Hemoglobin level among antenatal mothers
in data, highest percentage (48%) of the samples belonged to 9 -10.9 gm/dl blood hemoglobin level and 26% belonged to ≥11gm/dl and 24% belonged to 7-8.9gm/dl only2% were belonged to<7gm/dl.The data is also presented in bar diagram shown in figure 9.
Table 12 Blood haemoglobin level among antenatal mothers who are in 1st stage of labour N = 50 Sl no Blood haemoglobin level Frequency (f) Percentage (%)

≥11gm/dl
Table 13 shows that the mean and standard deviation of blood haemoglobin level among antenatal mothers.Data depicts that mean score is 10.09 and standard deviationis 1.6.The remaining foetal outcome such as still birth, intra uterine death and any other related complications were not found in any of the sample so the relationship between these variables and maternal haemoglobin level was not tested.

Conclusion
On the basis of the findings of the study, the following conclusions have been drawn:  The samples were taken only from government hospital  In the sample characteristics of mothers the highest percentage (56%) of the sample belonged to the age group of 24 -29 years.Highest percentage (80%) of the sample belonged to Hindu religion and highest percentages (80%) of the samples were employed.No one got married in the age group of more than 31 years.Majority of them that is 70 % were primi gravida mothers. The sample characteristics of babies are highest percentage (54%) of the samples were male babies , highest percentage (58%) of the samples were between 2.5-3.5 kg birth weight.36% of the samples were pre term babies and 64% were term babies and 36% of the subjects had ≤37 weeks of gestational age that 96% of the samples had no history of intra uterine growth retardation . The blood hemoglobin level of 50 antenatal mothers who are in 1st stage of labor depicts that highest percentage (48%) of the samples belonged to the group of 9-10.9 gm/dl blood hemoglobin level and 26% belonged to the group of ≥11 gm/dl and 24% belonged to 7-8.9gm/dl only2% were in the group of <7gm/dl. A significant relation was found between maternal hemoglobin level and fetal outcome  A significant association was found between maternal hemoglobin level and demographic variable only religion at 0.05 level of significance

Table 1
Demographic characteristics of mothers in terms of age and religion N=50

Table 2
Demographic characteristics of mothers in terms of education N = 50 presented in table1shows that highest percentage( 56%) of the sample belonged to the age group of 24 -29 years, 40% belonged to 18-23years and only 4% belonged to the age group of 30-35years.This table also depicts that highest percentage (80%) of the sample belonged to Hindu religion.Only 20% belonged to Muslim religion.
The data presented in table 2 indicates that maximum (64%) of the samples were educated up to high school.20%had primary school education and only 16% had pre university education.Data

Table 3
Demographic characteristics of mothers in terms of age at marriage and place of residenceN = 50 The table number 3 shows that the demographic characteristics of mothers in terms of age at marriage and place of residence.The findings related to age at the time of marriage revealed that out of 50 subjects highest percentage (72%) were married between 19-24years, 16% marrie d between 25-30 years, while those married less than18 years of age comprised only 12% and no one got married in the age group of morethan31years.With regard to the place of residence 100% of the samples were from rural community.

Table 4
Demographic characteristics of mothers in terms of type of family N = 50

Table No .
4shows that majority (78%) of the mothers comes from joint family background and only 22% lived to nuclear family.

Table 5
Dmographic characteristics of mothers in terms of gravida, parity, abortion and living child N = 50

Table number 5
depicts that demographic characteristics of mother in terms of gravida, highest percentage (70%) of the sample were in G1, 18% of the sample were in G2 and remaining 12% were in G3 .In case of parity highest percentage (70%) of the sample were in P1 , 18% of the sample were in P2 and remaining 12% were in P3 But in case of abortion, 100% of the samples had no history of abortion.The sample distribution according to living children shows that majority (70%) of the sample had 1 child, 18 % of the sample had 2 children and remaining 12% of the sample had 3 children.PART 1 B -Demographic proforma for babyThe data obtained to describe the sample characteristics of the babies are sex of the new born, birth order, birth weight, colour of the new born, muscle tone, pre term birth, IUGR, gestational age in weeks, intra uterine death, still birth and any other related complications,

Table 6
Demographic characteristics of babies in terms of sex and birth orderN= 50

Table 7
Demographic characteristics of babies in terms of birth weight N = 50

Table 8
Demographic characteristics of the babies in terms of colour of the new born and muscle toneN = 50The demographic characteristics of the babies in terms of colour of the new born and muscle tone are shown in table number 8. The findings revealed that majority (84%) of the new born were completely pink at birth and only 16% had body pink and extremities blue.It also reveals that highest percentage (84%) of the new born had active body movements at birth and only 16% had flexion of extremities.

Table 9
Demographic characteristics of the babies in terms of pre term birth N = 50

Table 10
Demographic characteristics of the babies in terms of IUGRN = 50

Table 11
Demographic characteristics of the new born in terms of gestational ageN = 50 The table number 11 shows that the demographic characteristics of thenew born in terms of gestational age.The findings related to the gestational age of thenewborn reveal that 64% of the subjects had 38 -42 weeks of gestational age and36% of the subjects had ≤37 weeks of gestational age.

Table 13
Mean and SD of blood haemoglobin level among antenatal mothers N = 50

Table 14
Chi square computed between maternal haemoglobin level and low birth weight of the new bornN = 50

Table 15
Chi square computed between maternal haemoglobin level and colour of the new born N = 50

Table 16
Chi square computed between maternal hemoglobin level and muscle tone of the new born N = 50

Table 18
Chi square computed between maternal haemoglobin level and pre term N = 50

Table 19
Chi square computed between maternal haemoglobin level and gestational age N = 50

Sl. No. Maternal haemoglobin level Gestational age χ2 df Remarks <37weeks 38- 42weeks
The Chi-square values were greater than that of table value at 0.05 level of significance.Thus the null hypothesis H 01 was rejected and research hypothesis was accepted.But IUGR is not significant because the calculated value is less than table value.

Table 20
Chi square computed between maternal haemoglobin level and selected demographic variablesThe Chi square presented in table 20 shows that religion (χ2=5.45P<O.05) was significant at 0.05 level.The Chi-square values were greater than that of table value at 0.05 level of significance.Thus the null hypothesis H02 was rejected for this variable but accepted for age, education, occupation, and monthly income, type of family, place of residence, age at marriage, gravida, parity, abortion, living child, sex, and birth order